Demystifying the Emergency Department

Reality television and the public’s fascination with medical tele-dramas have conjured an image of the emergency department (ED) that could only be described as fantastique.

The metrosexual emergency physician in his early-thirties, attired in surgical blues, having just come to work after a session in an inner-city gym. A cup of Starbucks in one hand, his iPhone in the other. At his sides, a perfectly sculpted blonde nurse and gorgeous young Asian princess intern, both with stethoscopes slung over their necks. The three heroically save half a dozen lives per shift, amongst the dramas of their personal love-lives and careers.

The patient load is intense: major trauma; epileptic seizures requiring general anaesthesia to control; heart attacks requiring urgent heart transplants (“EKG, stat!”); women presenting with prolapsed umbilical cords with no time to get to the labour suite; and every episode has to have some sad tale of a child who is brought in because he has lost his parents (at this point even those without a stomach for blood and guts can open their eyes).

In contrast to this Michael Crichton world, we have another spin: horror stories about EDs are almost a daily occurrence in our tabloids and on the television news. In the Murdoch world, we hear of women having miscarriages in the toilets, patients dying whilst awaiting admission to the main hospital wards, children with meningitis being misdiagnosed. We hear complaints from the ambulance service about their officers being made to wait hours with patients on trolleys until an ED bed is free. Almost weekly, emergency doctors remind us that they cannot keep up their workload and another rural ED reports being with no doctors.

Over the last sixteen years, I have had the pleasure (or misfortune?) of working in EDs of all shapes and sizes. With this in mind, I wish to demystify Australia’s EDs. 

First, what is an ED? Second, who are the emergency doctors? Let the demystification process begin!

What we are presented with in the media, be it the fantasy or the horror, is generally speaking the large city teaching hospital ED. In reality such departments are by far the minority of EDs in Australia. EDs vary from single-bed set-ups in bush clinics, all the way up to the aforementioned settings of the television series. Big departments are often subdivided into all sorts of wings—acute care, surgical care, paediatrics, sometimes even operating suites and labour suites. Most EDs are somewhere between the two extremes. They may be staffed by permanent doctors and nurses, or by an on-call system in smaller settings. 

Whilst specialist emergency physicians and nurses are usually quoted as representing EDs in Australia, most doctors and nurses working in EDs are in fact generalists, such as GPs and junior doctors. Emergency physicians tend to be found only in large city EDs and large regional EDs. Even in those large departments, emergency physicians make up a minority of the medical staff.

The whole field of emergency medicine and emergency physicians is fairly new; the Australasian College of Emergency Medicine was founded only in 1984. As a young craft group, emergency medicine is still finding its feet and as a result is still trying to establish not only its identity, but also its role. 

Many in the medical profession hold the view that emergency medicine is not a distinct specialty in its own right. Such doctors believe that all doctors should possess emergency skills, and within each traditional specialty there are people who are more expert than the emergency physicians. Therefore the cardiologists will always maintain that they know more about hearts. Orthopods will always know more about fractures (and rugby and sailing). Obstetricians will always be better able to handle confinements. And so it goes. What makes it worse is that emergency physicians often have to call upon those other specialists to bail them out of trouble in dicey situations. 

Looking from the bottom up, from the perspectives of the general practitioner and junior medical officer, one sees emergency physicians more as administrators rather than practitioners. This is because the emergency physician is usually the one on the phone or in the office rather than with the patient. 

The lack of identity and role has not stood in the way of emergency medicine rapidly evolving into a highly influential specialty in the medical food chain. It wields power via the fact that the ED is the gateway to hospital beds and at the same time the main hospital interface with the public and non-hospital doctors. Furthermore, the ED is also the interface with emergency services, which also confers the ability to attract media interest.

One thing most in the profession do agree upon, and funnily enough so do the public and politicians, is that EDs in Australia are under a lot of stress. This stress is due to a bad evolution—a devolution and devaluation—brought about by an insatiable demand for services that is not met by the supply of ED beds or ED staff. The reasons for this are complex, and I touched on many of these in an article (“Twelve Steps to Real Health Reform”) in the July-August Quadrant.

If EDs restricted themselves to emergency work, there would be no problem: they would be adequately resourced and staffed to do what they are meant to do. However, the definition of an emergency has become very rubbery, as we live in a society that seeks instant gratification, with a twenty-four-hour self-service culture, garnished with political imperatives of being seen to be providing free health care to all, no questions asked.

Society has to bear a lot of the blame for the devolution of the ED. The public uses EDs in the same way as a corner store. The doctors and nurses are like vending machines. Convenience has replaced acuity as the determinant of why someone presents. 

The difference between the ED doctor and the vending machine is that the vending machine will not dispense an item unless it has first been paid for. This is not the case in Australian EDs, with the exception of the very few private EDs that are to be found in some of the major capital cities. 

Patients in Australia have worked out that attending a GP, even a free bulk-billing GP, can be a process that involves a modicum of effort such as making a phone call to make an appointment, and later a visit to a pharmacy, and perhaps also a visit to a specialist or allied health practitioner. Presenting to an ED often avoids such inconveniences, for at this one-stop-shop all will be done within a few hours, unless you have the shock-horror of needing admission. 

Sprain your knee playing tennis? Go to a large ED, and there is a good chance that you’ll be seen by a doctor, be given some drugs, see a physio, and maybe even an orthopaedic registrar to boot! So why would you bother going to see a GP? I guess it depends on whether you want to eat a cheeseburger or filet mignon. 

Politicians are unwilling to address this problem. Any tweaking of free medicine is seen by the modern-day politician as electoral suicide. Promoting his autobiography recently, Tony Blair finally dared to say that free medicine is unsustainable in advanced economies. It is a great shame that our politicians will only act once our health system is totally broken and has rendered our national economy bankrupt. 

As we have seen in the insanities surrounding climate change and carbon taxes, politicians know that putting a price on something reduces demand. And so it is with EDs. Most of us who work in EDs are convinced that even a nominal fee would make people think twice about presenting, especially with trivial matters. 

The question arises as to what to do with people having genuine emergencies. A simple solution would be a rebate system based on clinical grounds. A real emergency would not be charged. 

Sticking with the concept of environmentalism, another feature of the ED devolution is its new role of waste disposal and recycling for other agencies. Imagine a police officer or social worker confronted with a problem of a behavioural, petty criminal or domestic nature. Rather than go through the reams of paperwork, or sorting out the mess, it is easier for the troubled one to be dumped in an ED. The real problem is recycled into something vaguely medical, with mental health being the trump card that they usually throw in when all else appears implausible. The caring ED doctors and nurses are then left to offer food, shelter and lessons in basic life skills. Because EDs are not in fact designed to provide ongoing or chronic care, or to be social welfare agencies, the solutions presented to these people in ED are often inappropriate and very short-term.

It is a shame that Centrelink offices and banks are not open twenty-four hours a day, as this would certainly reduce ED presentations. 

There is a shortage of hospital beds in Australia and most of the larger hospitals are overloaded, in many instances without the capacity to take acutely sick patients. This results in ED bed blocks as patients wait to be admitted to the wards. And because it is now so hard for doctors to have their patients admitted to hospitals for conditions that whilst not emergencies are still serious, ED has become the back door into the wards.

Recently a colleague of mine saw a six-month-old infant with new-onset epileptic seizures. The child needed to have neurological investigations and consultations. After spending hours making numerous phone calls, the GP was told that the child would need to wait six months to see a paediatric neurologist and was instructed to send the infant to the ED if the problem was deemed more urgent than six months.

Sadly many specialties, especially the paediatric sub-specialties, in Australia have now been monopolised by the public hospital system, so that inappropriately sending people to the ED is the only real way to receive attention in a timely manner. Wanting to protect himself from litigation and other forms of complaints, the community doctor is in a real bind.

What happens once one is through the big plastic swinging doors also needs to be demystified. 

Definitive treatment is not always the goal. EDs also have a holding and triage function in their own right—a waiting room after the waiting room. For patients with multiple medical problems or a single complex problem, not only is the ED another waiting room, but also an auction hall. At this point the emergency doctor becomes the auctioneer, but instead of awarding the patient to the highest bidder, he awards it to the bidder who offers the least resistance. 

The auctioneer also needs good diplomatic skills, as he has a dual negotiator role—that of medical negotiator and that of industrial relations negotiator. Diplomatic skills commensurate with those of a UN attaché are called for in many cases to find a team or specialists or other hospital willing to take on the patient. This may appear to be a relatively simple task, logically determined by the most acute or important need of the patient. Reality is quite different. 

Generalists are a thing of the past in large regional hospitals and the city teaching hospitals. This is a great national shame. It is one of the chief reasons why patients experience bedblock and find it hard to move out of the ED.

Because of bed shortages and because many hospital departments are driven by tight budgets and performance targets, the process of moving patients from the ED is cumbersome and political. For instance, a patient with unstable diabetes and pneumonia will be subject to fierce quarrels between the endocrinologists and thoracic physicians. The endocrines will say they have no beds and so will the thoracics. The second phase of the argument will be that the pneumonia is more critical than the sugars, and vice versa. 

A by-product of all this jostling and trading is that a patient will often be subjected to a battery of unnecessary tests. These investigations are to build a case for a department to accept a patient that they should be accepting anyway. Tests also fill time so that the ED doctor can somehow save face with the patient and “explain” why the patient cannot be moved on from the ED. A classic example is appendicitis. It is well-known to all students of medicine that appendicitis is diagnosed by the laying of a hand on the abdomen of a patient. There is no role for blood tests. There is no role for scans. However in large hospitals, it is now almost de rigueur for patients with appendicitis to be subjected to blood tests and CT scans—this fills in time as ED doctors and surgeons find a way of adding the patient to some emergency operating list that will not disrupt elective surgery.

In rural and small urban hospitals the emergency doctor also has to play the role of the transport officer and industrial relations clerk. In these settings, patients frequently need to be sent to bigger centres in order to receive definitive care. Whilst rural doctors are quite skilled at handling a myriad of pathologies, a lack of nursing staff, lack of equipment, and lack of diagnostic services mean that many patients need to be transferred even though the doctors are quite capable.

When ambulance officers whine about being stuck for hours in ED holding bays with patients on trolleys, they lose sight of the fact that in smaller hospitals they often create the problems. The ambulance officers are sometimes the victims and also sometimes the villains.

For example, if an ambulance comes to the aid of a woman in labour it would be sensible to take her to an obstetric facility. Instead she is often taken to the nearest hospital, even though it may be an inappropriate one. The hapless ED doctors and nurses then have to manage a woman in labour, hoping she does not deliver dangerously in their ill-equipped hospital. Simultaneously, they need to find an obstetrics unit to accept the patient, and then persuade the centralised ambulance co-ordination call centre that an ambulance is needed to ferry the patient to where the ambulance should have ferried her in the first place. All this jeopardises patient safety, burns out staff in small hospitals and costs taxpayers millions per year in extra call-out fees for doctors and ambulance officers. 

At this point industrial relations come into play: the ambulance co-ordination centre will try to find excuses not to transport some patients. In the first instance they will manufacture excuses based on clinical grounds. Failing that, the next step is to quote occupational health and safety concerns for their officers. After exhausting those two arguments, they finally offer the truth and admit that they want to save on penalty rates and overtime for the ambulance officers. 

Rather than continue the policy of dumping patients at the closest ED in order to save wage costs, health departments should establish a system whereby patients are taken to the most appropriate place in the first instance. 

An anomaly that cannot go unmentioned relates to very fat patients. If someone weighing about 180 kilograms or more dials 000, the ambulance will transport him to the closest emergency department. If an ED doctor needs to send that patient elsewhere, he needs to be ready for a prolonged stay on the trolley. The doctor dons the occupational health and safety cap. The ambulance co-ordination centre will declare that patients of 180 kilograms or more need the bariatric vehicle. The fat truck! Those of us working in western New South Wales wait up to twenty-four hours to transfer our patients, as the fat truck is stationed in Sydney and needs to be driven out west by the fat-truck officers. Never mind that the patient was brought in by the local ambulance. Never mind that the patient may only need a thirty-minute journey down the road—the powers-that-be insist that the fat truck is the only mode of transport for such patients. It is tempting for us rural doctors to call the local wheat carter to take the patient down the road; however, the wheat carter would not be silly enough to do business with the hospital administration, who would never pay him on time!

EDs need cooks. I do not refer to chefs feeding hard-working emergency physicians after their long gym sessions. Nor do I mean nourishing patients waiting hours or days to be moved down the corridor to the wards.

The cooks are administrators who have to cook the books to please the bureaucrats at the Department of Health. At the smaller, less sophisticated hospitals, cooks do their cooking after the patient has left, by fine-tuning statistics, diagnostic categories and other such items, to make it look as if the department is performing better than it is. In the more sophisticated departments, the cooks start cooking from the moment the patient arrives, deciding on how the patient is to be triaged, whether the patient is to be counted as an inpatient or an outpatient, and so on. The creative accounting and instruments used would make any junk bond trader on Wall Street very proud. No Theory of Relativity, cosmological strings or quantum mechanics can match the distortions made to time and matter by hospital administrators. 

In EDs man cannot live on bread alone, but only the manna of the cooks. 

The term “Emergency Department” is a misnomer. Nanny-state governments have devolved EDs into their twenty-four-hour outlets to cater for the social dysfunction that they aid and abet. Politicians and senior bureaucrats can sleep soundly knowing that the ED doctors and nurses are cleaning up the mess. 

Dr Aniello Iannuzzi is a rural doctor in New South Wales. He is the author of Being Human: For Human Beings (Fontaine Press, 2007).